Performance evaluation of the fraud management system in health insurance

Efficient insurance fraud management can have significant effect on insurance companies’ competitive market position. Potential savings accumulated in fraudulent activities can add up to 10% of all expenses insurance companies pay for damage claims, which globally add up to several 100 billion Euros. There are various available methods to detect insurance fraud. The simplest one, that is to manually review a small number of insurance claims, is highly inefficient and its success rate is largely dependent on investigator’s luck to select the exact cases that would turn out fraudulent after investigation. It is more efficient for investigators to use information technology that systematically highlights all cases which are identified as suspicious by predetermined criteria. Thereby, the investigators can focus solely on the potentially interesting cases. The implementation of fraud management information system into the business system of an insurance company also demands measuring the effects of such a system on its business performance. These effects can be divided into two categories: direct and indirect. The direct effects relate to quantity, value and the relevance of detected frauds, while the indirect effects give an estimation of fraud prevention effectiveness among individuals who are most likely to commit fraud. Direct effects can be measured and directly taken into account when calculating insurance company’s business success. Indirect effects, however, cannot be measured this way for most insurance lines. A high level of fraud diversification and randomness is hard to encapsulate into prediction models, especially those capable of forming estimates with an sufficient degree of confidence to be included in the insurance company’s savings estimates. However, the assessment of indirect savings is to a certain extent feasible in some insurance lines where the number of potential fraudsters is limited and relatively small. For such cases, it can be presumed that once fraudulent activity is detected and sanctioned, it will no longer occur or it will occur to a lesser extent. In fore mentioned systems assessment can be made on the basis of the differences in the dynamics of occurring suspicious fraud cases. An example of such insurance line is health insurance. The result of the master’s thesis is an extended assessment method which can be used to evaluate the performance of health insurance fraud management systems. The method takes into consideration both the direct savings and the assessment of indirect effects which occur as a result in the systematic fight against fraud. With the help of the suggested method the health insurance companies gain not only a full overview of the success and efficiency of the fraud management processes but also an assessment of how these influence the business performance of an entire insurance company

Odnos med komponentami zavarovalniških družb in kakovostjo njihovih storitev

Background and Purpose: An increasing number of insurance companies and the intensity of competition in this field require research on customer perceptions of the components of insurance services and insurance company. The objective of this study was to examine the conceptual model and to study the relationships between customer perceptions of the innovation, reputation, adequacy of premium, and adequacy of information about the coverage of insurance services. Design/Methodology/Approach: The research model was tested with structural equation modelling (SEM) with a sample of 200 Slovenian users of insurance services. Results: The results indicated that higher perceived innovation of insurance company was associated with higher perceived reputation of insurance company. In addition, higher perceived reputation of insurance company was associated with higher perceived adequacy of information about the coverage and the premium for insurance services. The study also found that higher perceived adequacy of premium was associated with higher perceived adequacy of information about the coverage of insurance services. Conclusion: The original contribution of this article is also the highlighting of relationship between perceived reputation of insurance company, perceived adequacy of information about the insurance premium and perceived adequacy of information about the coverage of insurance services.Namen: Povečevanje števila zavarovalnic in intenzivnost konkuriranja na trgu zahteva raziskovanje uporabnikovega zaznavanja komponent zavarovalnih storitev in zavarovalnic. Cilj študije je bil proučiti konceptualni model in odnose med uporabnikovim zaznavanjem inovativnosti zavarovalnice, ugleda zavarovalnice, ustreznosti informacij o zavarovalni premiji in ustreznosti zavarovalnega kritja zavarovalnih storitev. Metodologija: Raziskovalni model je bil testiran s pomočjo modeliranja s strukturnimi enačbami, na osnovi vzorca 200 slovenskih uporabnikov zavarovalnih storitev. Rezultati: Rezultati raziskave so pokazali, da višja kot je zaznana inovativnost zavarovalnice, višji je zaznani ugled zavarovalnice. Ugotovili smo tudi, da se višji zaznani ugled zavarovalnice odraža v višji zaznani ustreznosti informacij o zavarovalnem kritju in zavarovalni premiji zavarovalnih storitev. Študija je še pokazala, da višja kot je zaznana ustreznost informacije o zavarovalni premiji, višja je zaznana ustreznost informacij o zavarovalnem kritju zavarovalnih storitev . Sklepne ugotovitve: Izvirnost znanstvenega prispevka se kaže v obravnavanju odnosa med zaznanim ugledom za - varovalnice, zaznano ustreznostjo informacij o zavarovalni premiji in zaznano ustreznostjo informacij o zavarovalnem kritju zavarovalnih storitev

Cyber insurance

Kibernetsko zavarovanje predstavlja relativno nov produkt, katerega razvoj je bil, zaradi vseprisotnega razvoja tehnike in pametnih naprav, neizbežen. Zaradi inherentnih lastnosti kibernetskega tveganja, ki ga s kibernetskim zavarovanjem zavarujemo (njegove sistemskosti, korelacije, neopredmetenosti in dinamičnosti), zavarovalnice niso naklonjene zagotavljanju širokega kritja. Prav tako nadaljnji razvoj trga kibernetskih zavarovanj preprečujeta odsotnost standardizacije ter enotnih definicij pojmov v zavarovalnih pogodbah. To velja tako za samostojno kibernetsko zavarovanje, kot za pasivna kibernetska zavarovanja, med katerimi je najpogostejše zavarovanje splošne odgovornosti. Predstavljeni izbrani primeri iz ameriške sodne prakse potrjujejo zmedo na trgu kibernetskih zavarovanj in kažejo na to, da je obseg kritja v največji meri odvisen od vsakokratnih konkretnih okoliščin primera in besedila zavarovalne pogodbe, predvsem izključitvenih klavzul. Za nadaljnji razvoj kibernetskega zavarovanja je pomembno sodelovanje med državo in zavarovalnicami, ki bi morale družno delovati v smeri čim večjega sklepanja kibernetskih zavarovanj s širokim kritjem, saj preventivni ukrepi, ki jih ob sklenitvi zavarovanja od zavarovalca zahtevajo zavarovalnice, pozitivno vplivajo na kibernetsko varnost kot javno dobrino.Cyber insurance is a relatively new product whose development was inevitable due to the omnipresent development of technology and smart devices. Because of the inherent characteristics of cyber risk, which is insured with cyber insurance (it is systemic, correlated, intangible and dynamic), the insurance companies are not inclined to providing a wide coverage. Lack of standardization and uniform definitions of terms in insurance contracts prevent further development of cyber insurance market. This is the case in both, stand alone cyber insurance contracts and non-affirmative insurance contracts, among which commercial general liability contracts are the most common. The selected cases from the US case law confirm confusion in the cyber insurance market and show that, to a large extent, the coverage depends on the particular circumstances of each case and the wording of insurance contract, especially exclusion clauses. For further development of cyber insurance, cooperation between states and insurance companies is important. They should work together to maximize the number of cyber insurance contracts with broader coverage, because the preventive measures, which the insurance company imposes on the insured when concluding the contract, have a positive impact on cyber security as a public good

Statistična ocena protipožarne varnosti večstanovanjskih zgradb v Sloveniji

Skoraj tretjina stanovanjskih enot v Sloveniji se nahaja v večstanovanjskih objektih. Večina tovrstnih zgradb je bila zgrajena po drugi svetovni vojni, ko je bila potreba po ustreznih nastavitvenih objektih največja. Narejeni so bili v okviru gradbenih možnosti in zahtev časa. Vsako leto v teh objektih izbruhne več kot 200 požarov s smrtnimi žrtvami in z veliko gmotno škodo. Zaradi velikih naporov v preteklih stoletjih, ki so bili usmerjeni predvsem v zamenjavo gorljivega gradbenega materiala z negorljivim in z razvojem gasilske službe, sta se število požarov in njihov obseg zmanjšala, vendar ne odpravila. Nov, večji napredek na področju požarne varnosti večstanovanjskih zgradb je tako očiten šele v zadnjih nekaj letih, ko veljajo tudi strožji predpisi za gradnjo tovrstnih objektov. Razvoj znanosti in stroke je tudi na tem področju prinesel več novih rešitev za izboljšanje stanja, kar potrjujejo izkušnje iz tujine. Žal je pri nas uveljavitev varnostnih principov še vedno odvisna predvsem od zavesti uporabnikov, finančnih sredstev, hkrati pa so določeni postopki izvedbe bistveno bolj zapleteni zaradi novih lastniških razmerij. S pomočjo statističnih rezultatov popisa 2002 in sodobnih zahtev varstva pred požarom se želi v članku prikazati današnje stanje tega problema na državni in občinski ravni ter nakazati možnosti izboljšanje stanja. Avtorja v članku ugotavljata, da sodobnim zahtevam ne ustreza pravzaprav nobena starejša večstanovanjska zgradba. K sreči izboljšuje stanje na tem področju dejstvo, da je večina objektov pri nas zgrajena iz negorljivih materialov (beton, opeka), ki omejujejo širjenje požara

Implementation of an information system for managing risky persons in an insurance company

Risk management that is connected with the customers of the insurance companies is a great challenge for the insurance companies, for they can prevent negative consequences by managing the latter. Globally, the insurance companies are confronted by insurance frauds which are one of the biggest risks of the insurance industry. Different sources state that approximately 10 percent of all the paid out claims is a consequence of the fraud. ACFE organization estimates in its study that the amount paid to the swindlers amounts to the 5 percent of all the income of the insurance companies. Most of the discovered frauds is connected with a long-term legal procedures; therefore, it is essential that an insurance company establishes an efficient system in order to prevent the frauds and upgrades it with the system of managing the risky persons, which includes all the risks of the clients that are stored in patterns and rules and are used for the needs of preventing. In the master’s thesis, an information system for managing risky persons, which includes the lists of persons different in contents, is developed. The criteria for placing on the lists are determined on the basis of past experiences of the insurance company and expert system for the detection and researching the frauds. In order to establish the information system, a data model, processing for the automatic placing of the persons on the lists, application for editing, erasure and entry of the lists and persons, had to be developed. In order to establish the information system the display of indicators in all the key applications of the insurance company with the manual of user’s managing of the application in different processes of handling the clients had to be established. The system includes the lists of persons who performed an insurance fraud in the past, were a part of judicial proceeding, were insolvent, were defaulted obligors of the insurance premium, persons liable to recourse, have bad damage results, have bad insurance-technical result and are risky from the perspective of large damage frequency. Financial effects of the development of the information system will appear in a long-term period, for the insurance business is an industry where an insurance company and a client have little contacts; measuring the effects of the developed information system is possible only at concluding insurance contracts and in settlements of the claims. An established system for managing the risky persons is an infrastructure or the framework for further development and the opportunity for further work connected with the inclusion of life, pension and medical insurances as well as possible completion of the lists also with the persons that bring above the average yield, or important clients of the company, for the infrastructure enables all that